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Medicare makes it tougher to get equipment

Alice needed a walker. She had become frailer following a hospital stay. Sounds simple, and it used to be simple to meet this need. Not necessarily any longer. Things have changed and you will want to know about this.

Alice had her doctor fax the order to a medical supply company in Medford. In the past, they would submit this to Medicare, and in a few days at most, she would have the walker she needed. It didn’t happen. After many phone calls, I found out that in order to submit a bill for this piece of medical equipment, they needed explicit chart notes from her last visit to her doctor.

Now the calls shifted to her physician’s office to attempt to have these chart notes sent over. Weeks later (I kid you not) the notes had finally arrived, but were insufficient. For Medicare purposes, they needed a detailed assessment of her actual needs before they would proceed. I was sure it must have been a problem with this company, as I had never seen this happen in the past.

Things have become so complex that one of the oldest local resources for what is known as durable medical equipment (DME), Phoenix Pharmacy, is no longer billing Medicare for any of this. It was not the fault of the company in Medford, either. It’s just a big problem for all of them, and some are opting out of even dealing with this.

To see what more I could find out, I spoke to Scott Armas, medical equipment specialist at Ashland Drug (53 N. Second St.; 541-482-3366). He told me that Medicare always had these rules and regulations, but is now really requiring them to be met. He showed me all the forms that now need to be filled out, and it’s a lot of work for doctors and equipment providers. One of those rules is that the equipment provider needs to do an assessment at the person’s residence to see if the requested equipment is actually needed and will function there. Time consuming all around.

For those who don’t want to go through this process, you can always purchase the equipment out of pocket, of course. There are often lightly used items for sale in the newspaper. ACCESS in Medford (3630 Aviation Way; 541-779-6691) has always kept these donated items on hand, for those who could not afford it or may not have had insurance coverage.

Here is additional important information from Scott Armas:

  • What are the difficulties you are seeing for those needing medical equipment and Medicare paying for this?

Often the prescription is incorrectly filled out or missing key information, like the diagnosis code, not properly signed, etc. More often, the item requires a "face to face" encounter with the doctor, which never occurred, occurred too long ago (more than six months) or was insufficiently documented.

Additionally, the supplier must have the prescription and documentation in hand before the item is dispensed. Finally, there are many physicians who prescribe equipment which may be merely convenient or even helpful to a patient, but simply don't meet Medicare's definition of necessity.

  • What can the consumer and doctor can do to make this work more smoothly?

A consumer cannot help expedite the process and shouldn't need to try. Doctors want to prescribe equipment to help their patients, but need more information regarding coverage criteria. This includes a complete prescription, including chart notes stating the specific need for the equipment.

  • What has caused this problem?

There is a helpful booklet for providers called “The Medicare Face to Face Rules for Durable Medical Equipment” (http://tinyurl.com/pq6ld86). But what is really driving this is audits. A supplier can be on the hook for a claim for up to three years back. Trying to obtain "better" documentation after the fact, if the original material was possibly not quite sufficient, is next to impossible. No one can take the risk anymore and audits take too long to work through.

  • What is Ashland Drug doing to address this?

Ashland Drug is one small store, and like many others here locally, there is always the possibility of not billing Medicare for DME in the future. Right now, it’s still working. I am always happy to guide and instruct people regarding their mobility needs. Please call Scott at Ashland Drug for this help.

If you find yourself in this boat, make sure you and your physician have done everything that Medicare will ask for. Be patient with the process. Most of the time, it will work out.

Ellen Waldman is a certified Aging Life Care Professional. Email questions about aging and Ashland-area aging resources and column suggestions to her at edw@ashlandhome.net.